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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412635
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:40:41 PM

Document Has Been Signed on 09/25/2024 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MORALES, SHAELONFACILITY NUMBER:
434412635
ADMINISTRATOR/
DIRECTOR:		MORALES, SHAELONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 242-7671
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
09/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Shaelon MoralesTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Mandeep Kaur and Andy Yang conducted an unannounced annual inspection. LPAs met with Licensee, Shaelon Morales and explained the reason for the inspection. Present during today's inspection were Licensee with five children including 3 infants.

The hours of operations are Monday through Friday 07:30 AM to 5:30PM. There is a board to post required postings, such as license and notification of parent's rights. LPAs toured the inside and outside of the home with Licensee. There are age appropriate toys and equipment available for the children. Disinfectant and cleaning supplies were inaccessible to children.

LPAs obtained a copy of current children's roster during the inspection. Licensee was reminded of fire drill needs to be done every 6 months. LPAs observed a fully charged 2A10BC fire extinguisher, functioning smoke and carbon monoxide detectors. Licensee states that there are no weapons or firearms in the home.

LPAs reviewed Four (4) children's files during today's inspection. The children records reviewed include but not limited to immunization records and notification of parent's rights. LPAs reminded Licensee that the Mandated Reporter Training and Pediatric CPR/First Aid certifications shall be renewed by all staff every two years.

Facility provides breakfast, morning snacks, lunch, and afternoon snacks to the children. Healthy beverages requirements were discussed with Licensee.

Continuation on next pages:
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MORALES, SHAELON
FACILITY NUMBER: 434412635
VISIT DATE: 09/25/2024
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LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and
recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased
equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any
IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information
regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800)
514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

The adults 18 and over living in the home are Licensee. All adults have cleared criminal record and child abuse index. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address
provided. Please complete the survey and share your inspection experience. If you have any questions
regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional
information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/process.

**Continue on next page**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MORALES, SHAELON
FACILITY NUMBER: 434412635
VISIT DATE: 09/25/2024
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During the exit interview, the Licensee, Shaelon Morales confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Type B Deficiency is issued during today's inspection on 809-D.

Exit interview conducted and report was reviewed with Licensee, Shaelon Morales. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2024 02:40 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 09/25/2024 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MORALES, SHAELON
FACILITY NUMBER: 434412635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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By POC due date 10/09/2024, Licensee will submit the proof of infant safe sleep log for every 15 minutes and written statement of understanding the Title 22 regulations section code: 102425(j)(1): Infant safe sleep: physically check on the infants every 15 minutes.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


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